Radiology · Year 4 · from Radiology
Case 1: Transcatheter Arterial Chemoembolization (TACE) for Hepatocellular Carcinoma
Patient Demographics
- Age: 62 years
- Sex: Male
Chief Complaint
Incidental liver mass found on surveillance imaging
Presenting Symptoms
The patient has a history of hepatitis C cirrhosis (treated and cured with direct-acting antivirals 4 years ago) and undergoes routine hepatocellular carcinoma (HCC) surveillance. His most recent ultrasound showed a new 3.5 cm liver lesion. He is asymptomatic with no abdominal pain, jaundice, weight loss, or encephalopathy. He continues to abstain from alcohol.
Physical Exam Findings
- Vital Signs: Within normal limits
- General: Well-appearing male, no jaundice, no asterixis
- Abdomen: Soft, non-tender, liver edge palpable 2 cm below costal margin, no ascites, no splenomegaly
- Stigmata of Liver Disease: Spider angiomata on chest, palmar erythema
- Laboratory:
- AFP: 287 ng/mL (elevated)
- Child-Pugh Score: A5 (compensated cirrhosis)
- MELD Score: 8
- Platelets: 118,000/uL
- INR: 1.2
- Albumin: 3.6 g/dL
- Bilirubin: 1.1 mg/dL
Imaging Findings and Interpretation
Multiphasic CT/MRI Liver (LI-RADS Protocol):
Arterial Phase:
- 3.8 cm mass in segment 6 of the liver
- Arterial phase hyperenhancement (APHE) - enhances more than background liver
- No other suspicious lesions
Portal Venous Phase:
- Washout appearance - mass becomes hypodense relative to liver
- Enhancing capsule appearance visible
Delayed Phase:
- Persistent capsule enhancement
- Central hypointensity (washout confirmed)
LI-RADS Classification: LR-5 (Definitely HCC)
- Meets criteria: >20mm observation with APHE + washout + enhancing capsule
- No threshold growth needed given other features
Additional Findings:
- Cirrhotic liver morphology with nodular contour
- Patent portal vein, no tumor thrombus
- No extrahepatic disease on CT chest/abdomen/pelvis
- Small volume ascites
Staging:
- BCLC Stage A (single tumor <5cm, preserved liver function)
- Milan Criteria: Within (single tumor <=5cm)
Diagnosis
Hepatocellular carcinoma (LR-5), BCLC Stage A, in setting of HCV cirrhosis; candidate for curative treatment
Management
- Multidisciplinary Tumor Board Discussion:
- Hepatology, surgical oncology, interventional radiology, medical oncology
- Treatment Options Considered:
- Liver transplant: Listed for transplant (within Milan criteria)
- Surgical resection: Possible but higher risk given cirrhosis
- Ablation: Could be considered for lesion of this size
- TACE: Selected as bridge to transplant
- TACE Procedure (Bridging Therapy): Pre-procedure:
- NPO after midnight
- IV access, prophylactic antibiotics
- Conscious sedation
Procedure:
- Right common femoral artery access
- Celiac arteriogram: Identifies hepatic arterial anatomy
- Selective catheterization of segment 6 feeding artery
- Tumor blush confirmed on angiography
- Drug-eluting beads loaded with doxorubicin (100-300 micron)
- Embolization to near-stasis
- Completion angiogram: No residual tumor blush
Post-procedure:
- Post-embolization syndrome (fever, pain, nausea) managed supportively
- Discharged day 2
- Follow-up Imaging (4 weeks post-TACE):
- mRECIST assessment: Complete response
- No viable enhancing tumor
- Dense lipiodol retention (if conventional TACE) or non-enhancing treatment zone
- Transplant Listing:
- Maintained on transplant list
- MELD exception points for HCC
- Received liver transplant 8 months later
- Explant pathology: 100% tumor necrosis (pathologic complete response)
Radiological Image
Image Description: Selective hepatic arteriogram during TACE procedure showing hypervascular hepatocellular carcinoma with characteristic tumor blush (abnormal tumor vascularity). The catheter is positioned in the feeding artery for selective chemoembolization.
Source: Wikimedia Commons - "Hepatic angiography" URL: https://commons.wikimedia.org/wiki/File:Angiography_during_TACE.jpg License: Creative Commons Attribution-Share Alike 4.0 International